Nurses’ Guide: What Is the Crede Maneuver?

Crede maneuver is a urine voiding facilitatory technique that involves applying manual pressure on the lower abdomen. It’s usually accomplished in two successive steps.

First, you place your hands on the abdomen between the umbilicus and the pubic bone and stroke downward firmly to stimulate the voiding reflex. Then you exert pressure above the pubic arch by placing one hand on top of the other and firmly pressing inward to expel urine.

Essentially, exerting pressure through the abdominal wall increases the pressure in the bladder while relaxing the external urethral sphincter, allowing the urine to flow out through the urethra. This can be done when a person is sitting on a toilet seat/bedside commode, standing (male patients), or in a fowler’s (sitting) position in the case of an invalid.

However, you should exercise caution when performing the procedure as excessive pressure can injure internal organs. Also, in cases where the maneuver is performed wrongly, it can lead to urine backflow from the bladder up the ureters, a condition known as vesicoureteral reflux.

This procedure also increases the risk of complications under some conditions. For instance, a girl with a neurogenic bladder had a renal rupture after a crede maneuver.

For these reasons, the technique should be administered or supervised by someone who has undertaken a crede maneuver lesson. Patients can also perform the procedure on themselves after they have appropriate instructions.

Crede Maneuver example
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Origin of Crede Maneuver

Crede maneuver is one of many voiding facilitatory maneuvers (Valsalva, crede, suprapubic, etc.) It’s named after Carl Crede, a German physician (gynecologist and obstetrician).

Crede developed the method initially to help expel the placenta from the uterus after vaginal delivery. Crede maneuver was later adopted to aid in removing urine through a flaccid bladder.

Though it’s an inexpensive and non-invasive procedure, its efficacy at emptying the bladder is wanting. A urodynamic study that evaluated 207 patients suffering from various lower urinary tract disorders confirmed that the method could not be relied on to void the bladder completely.

Another study evaluating the reliability of crede maneuver in patients with urine retention reached a similar conclusion. In the study, patients who had undergone haemorrhoidectomy (a surgery for removing hemorrhoids or piles) were placed in two groups.

One group was taught crede maneuver, while the other was trained on traditional voiding methods. Though the non-crede group had a bladder emptying rate of 30%, the crede group’s rate was at 91%, indicating the inefficacy of the method to clear the bladder completely.

Application of Crede Maneuver

Crede maneuver is generally used on patients with the issue of urinary retention (UR). UR is caused by several factors, including neurogenic bladder, urinary tract infections, and prostate enlargement.

Neurogenic Bladder

Neurogenic bladder refers to an inability to control the bladder due to brain, nerves, or spinal cord problems.

Typically, when the bladder fills, the brain sends messages to the bladder muscles to hold the urine, then relax to release it when you are ready. When any of the coordinating organs are not functioning well due to illness or injury, bladder control is lost alongside.

The condition affects millions of people, including people with issues such as spinal cord injury, nerve damage, congenital disabilities, etc.

  • Spinal cord injury – Injury to the spinal cord may cause the patient to lose control over urination due to loss of feeling in the bladder. This results in a myriad of bladder problems, which may vary depending on the extent of the injury.

Note that spinal cord injury does not always cause loss of bladder control. Some patients still have feelings and can be able to control urination.

  • Nerve disease – Usually, nerves carry signals from the brain to the bladder and sphincter muscles. Nerve disease alters their functioning, resulting in either overactive bladder or urinary retention.

Overactive bladder involves sending signals at the wrong time. This often leads to issues such as high urination frequency, sudden urge to urinate, or urine leakage (incontinence).

Likewise, the nerves may fail to send signals, leading to the inability to urinate despite a full bladder (urinary retention).

  • Congenital disabilities – Some children are born with a neurogenic bladder, which is usually caused by defects in the spine (spina bifida, myelomeningocele, filum terminale syndrome, etc.) This results in an underactive neurogenic bladder, meaning the child is unable to empty their bladder.

Urinary Tract Infection

Urinary tract infection (UTI) refers to an infection on any part of the urinary system – kidneys, bladder, ureters, urethra. Types of UTI vary depending on the part of the urinary tract affected – acute pyelonephritis (kidney), cystitis (bladder), urethritis (urethra).

The prevalence of UTI is higher in women than men due to their makeup. Generally, UTI causes several issues, including urinary retention, cloudy urine, strong-smelling urine, burning sensation during urination, pelvic pain (in women), etc.

If left untreated, the condition often causes complications such as recurrent infections, increased risk in pregnant women, sepsis, permanent kidney damage, urethral narrowing, etc.

Benign Prostate Enlargement

Benign prostate enlargement is a medical term for enlarged prostate. The prostate is a gland in the male reproductive system which surrounds the urethra.

When the gland enlarges – benign prostatic hyperplasia (BPH) – it compresses the urethra preventing the free-flowing of urine from the bladder. The risk of developing BPH increases with age, with the rate hitting over 90% in men aged above 80.

Symptoms of BPH include urinary retention, dribbling after urination, and incontinence.

Urinary Retention

Urinary retention (UR) refers to an inability to empty the bladder. The condition can be chronic or acute.

Chronic urinary retention (CUR) is long-term. People suffering from the condition can pass urine, but the bladder does not empty fully.

On the other hand, acute urinary retention (AUR) is sudden and involves the inability to pass any urine, which makes it potentially life-threatening.

CUR develops gradually, meaning it can go undetected at the earliest stages. However, AUR is often accompanied by excruciating pain requiring immediate medical attention.

Generally, UR manifests differently depending on the type. Though initially hard to detect, chronic urinary retention symptoms include;

  • Difficulty starting urine flow
  • Inability to empty bladder completely
  • Frequent urination (exceeding eight times per day)
  • Urgent need to urinate
  • Pain or discomfort in the lower abdomen

Acute urinary retention symptoms include;

  • Inability to urinate
  • Severe pain in the lower abdomen
  • Swelling in the lower abdomen

Though the prevalence for UR is higher in older men, with the rate of AUR going up to 1 in 3 men aged 80 and above, both women and men of all ages can have urinary retention. UR can be caused by several factors, including urethra blockage, medications, nerve problems, etc.

Urethra Blockage

Blockage causes the urethra to narrow, making it difficult for urine to pass through. This can be caused by issues such as;

  • Bladder outlet obstruction
  • Constipation
  • Enlarged prostate (benign prostatic hyperplasia)
  • Pelvic organ prolapse
  • Tight pelvic floor muscles
  • Trauma to the pelvis or urethra
  • Tumors
  • Urinary tract stones

Inefficient Bladder Contraction

Inefficient bladder contraction is a problem characterized by loss of bladder muscle strength. As a result, the muscles fail to contract with enough strength and long enough to void the bladder.

Various factors can cause the issue, including;

  • Neurological problems from brain injury, diabetes, stroke, Alzheimer’s disease, Parkinson’s disease, spinal cord injury, vaginal birth, heavy metal poisoning, etc., can hinder sending of signals from the brain to the bladder
  • Medicines such as antidepressants, antipsychotics, opioids, antihistamines, antiparkinsonian medications, etc., may hinder nerve signals to the bladder
  • Weakened bladder muscles from aging, overdistention, pregnancy, and childbirth, etc.
  • Surgery – Medicine administered during surgery, e.g., intravenous (IV) fluid, often causes the bladder to fill up, while anesthesia prevents a person from feeling the urge to pass urine.

Note: Some types of surgery, such as hip replacement, rectal surgery, pelvic surgery, etc., can cause trauma, tissue scarring, or swelling, thereby interfering with the functioning of the bladder and urethra.

Dangers of Urinary Retention

Emptying the bladder, whether using crede maneuver or other methods such as urethral catheterization, is essential as prolonged urine retention can lead to severe complications. Some possible dangers of urinary retention include;

  • Urinary tract infection – Emptying the bladder flushes out any bacteria present in the urinary tract. However, when you cannot empty the bladder, the bacteria multiply, leading to infections.
  • Bladder damage – Accumulation of urine flexes the bladder leading to loosening of the bladder muscles, which ultimately hampers them from functioning correctly. Other than stretching, the bladder can also tear.
  • Kidney damage –  Full bladder means that the kidney can’t empty. As the kidneys accumulate the urine, they continue to contract, which can end up damaging them.

The urine can also travel back to the kidney from the bladder. Eventually, conditions such as kidney disease and kidney failure may develop.

  • Urinary incontinence – When the bladder gets damaged, urine leakage can happen whenever it fills up.

Equipment Used to Perform Crede Maneuver

Crede maneuver requires minimal equipment, unlike many other UR interventions. To perform the procedure on a patient, you only need;

  • A pair of gloves
  • A bedpan/urinal or bedside commode/toilet

How to Perform a Crede Maneuver

Crede maneuver is a simple procedure once you learn how to perform it properly. Below are the steps involved;

  • Verify doctor’s advice
  • Prepare the necessary equipment
  • Follow the hospital’s protocol to confirm the patient’s identity
  • Get the patient to relax by explaining the procedure
  • Get the patient into position (fowler’s position or standing) and set the urinal/bedpan, or assist them to the bedside commode/toilet
  • Place your palms on the patient’s abdomen below the belly button, then firmly stroke downwards severally to stimulate the voiding reflex
  • Apply pressure directly on the bladder by placing one hand on top of the other over the pubic arch
  • After exerting pressure on the bladder and triggering the voiding reflex on the urethral sphincter muscles, the urine should flow out

Complications of Crede Maneuver

Essentially, the crede maneuver should not be used as a primary method of bladder voiding but should complement other interventions such as self-catheterization or pending a medical procedure. Emptying the bladder using crede maneuver over a long time is not safe.

Possible complications include:

  • High bladder pressure
  • Abdominal bruising
  • Hernia
  • Hemorrhoids
  • Pyuria
  • Urinary lithiasis
  • Urethral dilatation
  • Hydronephrosis

Situations When Crede Maneuver Should Be Avoided

There are medical situations that may render the crede maneuver inappropriate. These include issues such as;

Alternatives of Crede Maneuver

As earlier indicated, the crede maneuver is not efficient in emptying the bladder completely. However, it’s a handy procedure that can be used as a temporal measure before procedures with a high efficacy rate are applied.

Alternatives of Crede Maneuver include;

Valsalva maneuver – This involves straining the abdominal muscles. To perform a Valsalva maneuver, you sit on the toilet and push down the way you do during a bowel movement. For added pressure, you can compress your lower abdomen with your forearm.

Suprapubic tapping – This involves tapping the area between your navel and pubic bone rhythmically to stimulate the voiding reflex. Essentially, you should tap the suprapubic region repeatedly for 30 seconds at one tap per second.

This should trigger the nerves and cause the external urethra sphincter to relax and let out urine.

Catheterization – In case of acute urine retention, immediate urine removal is necessary, which can be done using a catheter. However, catheterization can also be used for CUR cases.

This involves inserting a catheter inside the urethra to remove the urine, which can either be indwelling or intermittent.

With indwelling catheterization, the catheter is left in the bladder, while intermittent involves inserting on a need basis then removed after urination. Intermittent catheterization can be done at the hospital, or the patient can be taught how to do it independently at home.

Medication – Once the cause of the urinary retention has been established, an appropriate remedy can be administered to cure the problem. Medicine may include;

  • 5-alpha reductase inhibitors (treats prostate enlargement by shrinking it)
  • Alpha-blockers (relaxes the muscles in the bladder neck, and prostate)
  • Antibiotics (treats UR-causing infections), etc.

Medical procedures

  • Cystoscopy (finds and removes possible blockages such as urinary tract stones)
  • Laser therapy (breaks up the blockage to reduce obstruction)
  • UroLift (lifts the prostate back from the urethra to allow urine to flow through)
  • Vaginal pessary (combats urine leakage)
  • Urethral dilation (treats urethral stricture by increasing the urethral opening gradually)

Surgery – If the above interventions fail to resolve urine retention, surgery can be done as a last resort. This may include;

  • Repairing abnormal bladder
  • Removing a part of the prostate
  • Repairing pelvic organ prolapse
  • Repairing urethral strictures
  • Removing the urinary-causing tumor

Bladder training – Urination is a natural process that involves the contraction of the bladder muscles and relaxation of the sphincter muscles to let the urine out. When a person is anxious, the sphincter muscles may fail to relax, causing the holding back of urine.

Practicing relaxation techniques has been known to help some patients overcome the challenge of urinary retention. Relaxing allows the body to function normally, which helps the sphincter muscles open up the urethra for the urine to flow freely.

Therapy – Involves performing Kegel exercises (pelvic floor muscles exercises) to train the muscles to function optimally, enabling you to regain control over the pelvic area. Usually, the patient tightens and relaxes the pelvic muscles repeatedly, e.g., holding them tight for 5 seconds, then relaxing them for another 5 seconds and repeating the procedure about ten times, three times per day.

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Resources

https://pubmed.ncbi.nlm.nih.gov/6887405/

https://nursekey.com/credes-maneuver/

https://www.researchgate.net/publication/263407710_Effects_of_Crede’s_method_on_urine_voiding_within_the_first_8_h_after_surgery_among_post-haemorrhoidectomy_patients_A_comparison_study

https://www.urologysanantonio.com/urinary-retention

https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention/symptoms-causes

https://my.clevelandclinic.org/health/diseases/15427-urinary-retention

https://www.aafp.org/afp/2018/1015/p496.html#sec-3

https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-retention/definition-facts

https://lluh.org/conditions/urinary-retention

https://www.bergenurological.com/vfm.shtml

https://medlineplus.gov/ency/patientinstructions/000141.htm

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